Learners will manage an obstetrical complication of a retained placenta.
Jenna Bryan, a 33-year-old female (G3T1P1A1L2) presents to the ED with her husband following a spontaneous vaginal delivery approximately 1 hour ago at their family home. The baby was born at 37 weeks gestation, appears healthy, and is being examined by an RN in the ED.
The husband, seemingly distraught, informs you that Jenna continues to bleed. He informs you that their previous birth was in the hospital, and there were no complications, so they opted to have a 'freebirth' delivery of this baby at home. They had been receiving regular prenatal care. Her most recent prenatal visit was two weeks ago, with her next one being scheduled for tomorrow. The husband then leaves to check on their newborn.
You are the physician on call for labour and delivery at a rural 1A maternity site, and there is one RN available to assist you. The nearest urban centre is 300km away.
On examination, the umbilical cord will be presenting from the vagina, and the mother will be moderately bleeding. The learner will practice active management of the third stage of labour in the case of a retained placenta, using pharmacotherapy and manual maneuvers with the assistance of one RN.
This simulation is part of ØRECLESS (Rural Emergencies and Complications in Labour Events Simulations Suite).
Overall Goal: Manage a retained placenta following a spontaneous vaginal delivery.
Specific Learning Objectives:
Time Recommended: 60 minutes total (10 min Setup | 20 min Scenario | 30 min Debrief)
Patient Recommendation: Standardized Patient + OB Mannequin + OB Trainer
Medical Equipment:
Medications:
Other:
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This SIM requires one learner. Supporting roles can (1) be assigned to complete tasks by the learner, (2) provide assistance with maneuvers, and (3) provide statements throughout the SIM to allow for progression through the stages.
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Moulage: Set up with the placenta in situ and the umbilical cord cut and tied with thick string presenting from the vagina.
Set-Up: The woman is wheeled into the ED by her husband while holding her newborn. They both appear to be in visible distress.
Note: While prepping for your simulation, don't forget to prep for the debrief. Become comfortable with your chosen framework, review your objectives. For additional debriefing resources, see our Resources page.
Original Author: Kristen Palumbo
Originally published on: January 2, 2024
Most Recent Modification:
A good prebriefing is an essential component of running effective simulations, as it sets the stage for everything that comes after it1-3. An effective prebrief will create a safe container for learning, and in doing so, help participants feel more comfortable pushing their limits, sharing their thoughts and feelings, and buying into the experience. In turn, this will enhance engagement, participation, and learning. To that end, the prebriefing process needs to cover a lot of information1-5, which can make it daunting to novice or non-expert facilitators. To help, we have consulted the relevant literature and put together a prebrief guide to ensure that you have the tools you need to run an effective pre-briefing session.
Throughout the pre-brief, it is important that you convey your commitment to respecting learners and their perspective2-4, and establish and maintain the simulation as a safe space for learning1,4,5.
Prebrief Guide (Sample Phrases in Italics)
Welcome learners. Introduce yourself, your role, and your experience with simulation.
Go over the time requirements for the simulation, when breaks will occur, how learners should handle incoming calls or texts, etc.
Clarify the learning objectives for the simulation1-5. Give information on the purpose of the simulation without giving out specific actions or information that might compromise the learning experience for participants.
Explain how participants will be evaluated (formative/summative/not evaluated). Briefly discuss the debrief process that will take place at the end of the simulation.
Give details on what expectations are for the learners' behaviour during the simulation, setting basic ground rules2-5. Go over expectations for yourself as the facilitator. Reinforce the simulation as a learning environment, where mistakes aren't something to be punished but opportunities for further learning.
This could be a good place to pause and ask learners if they have any additional expectations, fears, comments, or questions about the topic for the day.
Ensure all participants agree to the confidentiality expectations of the simulation. Often, this will follow the mantra of "What happens in the simulation stays in the simulation," where learners and instructors agree not to share information on others' performance or scenario details outside of the simulation environment.
Explain that you've done what you can to make the simulation as real as possible, but acknowledge the limitations. Ask the learner to commit to doing what they can to act as if everything was real, explaining that the quality of their learning will depend on their willingness to participate as fully as possible. For the first simulation with a new group, it could be helpful to explain the importance of a mutual fiction contract.
Explain the different roles in the simulation and assign learners to them. If you have predetermined scripts for certain roles, hand them out here.
Explain the resources that will be available for the participants to use, how they should call for help in the simulation, what your role will be in providing information.
Orient participants to simulation space, equipment, manikin, etc. This can also be done by allowing participants to explore the simulation space and manikin for themselves.
Ask for questions!
References
1. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339-49. doi: 10.1097/SIH.0000000000000047. PMID: 25188485.
2. Leigh G, Steuben F. Setting Learners up for Success: Presimulation and Prebriefing Strategies. Teaching and Learning in Nursing. 2018; 13(3):185-189. https://doi.org/10.1016/j.teln.2018.03.004
3. Lecomte F, Jaffrelot M. Chapter 33 - Prebriefing and Briefing. Clinical Simulation. 2019; 2nd ed.; 471-482. https://doi.org/10.1016/B978-0-12-815657-5.00034-6.
4. INACSL Standards Committee (2016, December). INACSL standards of best practice: SimulationSM Facilitation. Clinical Simulation in Nursing, 12(S), S16-S20. http://dx.doi.org/10.1016/j.ecns.2016.09.007.
5. Simon R, Raemer D, Rudolph J. Rater's handbook for the Debriefing Assessment for Simulation in Healthcare (DASH) Rater Version. 2009. http://www.harvardmedsim.org/debriefing-assesment-simulation-healthcare.php.
Jenna Bryan, a 33-year-old female (G3T1P1A1L2) presents to the ED with her husband following a spontaneous vaginal delivery approximately 45 minutes ago at their family home. The baby was born at 36 weeks gestation, appears healthy, and is being examined by an ED RN.
The husband, seemingly distraught, informs you that Jenna continues to bleed. He informs you that their previous birth was in the hospital, and there were no complications, so they opted to deliver this baby at home. They had been receiving regular prenatal care. Her most recent prenatal visit was two weeks ago, with her next one being scheduled for tomorrow. The husband then leaves to check on their newborn.
You are the physician on call for labour and delivery at a rural 1A maternity site, and there is one RN available to assist you. The nearest urban centre is 300km away.
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Patient Chart |
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Name: Jenna Bryan |
Age: 33 |
Gender: F |
Weight: 93 kg |
Height: 172 cm | ||||||
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Temp: 36.8 |
HR: 110 bpm |
BP: 90/65 |
RR: 23/min |
O2Sat: 99% |
GCS: 15 |
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| Presenting complaint: Abdominal pain. | ||||||||||
33 y/o woman presents to the ED with her husband holding her newborn. You’ve called for assistance, but no other physician is available, and the other RN has left with the newborn to do an assessment. Only you and one RN are in the room with the patient, as her husband has gone with the baby.
Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.
| Patient Vitals | ||||
| BP: 90/65 | HR (Rhythm): 110 bpm (Sinus Tachycardia) | RR: 23/min. | ||
| O2SAT: 99% | Temperature: 36.8 degrees Celsius | GCS: 15 | ||
| Expected Learner Actions |
|---|
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Introduction (name and role) and confirmation of patient name and pronouns |
| 8 min. OR Actions Complete ⇒ 2. Preparation |
Pronouns: She/her
Pregnancy Records/ Complications:
Obstetrical History:
Medication(s): None.
Other: No Allergies. Insignificant family history and past medical history.
General Physical Exam: The patient appears fatigued and distressed, expressing concern about her newborn.
General Abdominal Exam: No visible asymmetry, lesions, or scars. No appreciable masses, swelling, rigidity, or guarding. Fundal height at the level of the umbilicus. Uterus is firm and globular in shape.
The third stage of labour has been managed physiologically so far. Inform the mother and her partner of the current situation and management plan. Ensure that the patient is hemodynamically stable.
Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.
| Expected Learner Actions |
|---|
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Explain to the mother (and partner) that she has a retained placenta |
| 2 min. OR Actions Complete ⇒ 3. Active Management of Third Stage |
The patient has agreed to active management of the third stage of labour. She continues to have some mild bleeding. Practice active management to deliver the trapped placenta.
Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.
| Expected Learner Actions |
|---|
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Administer Oxytocin, 5 IU IV over 1-2 min or 10 IU IM or 20-40U in 1L normal saline IV (150mL/hr) |
| 5 min. OR Actions Complete ⇒ 4. Continued Active Management |
30 minutes have passed, and the placenta has not yet been delivered. Bleeding has stopped, and the cervical os is now admitting 1.5 fingers. Address excessive cervical contraction.
Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.
| Expected Learner Actions |
|---|
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Instruct nurse to administer nitroglycerin
Continue to apply controlled cord traction |
| 5 min. OR Actions Complete ⇒ 5. Case Complete |
Within one minute of the nitroglycerin administration, the cervix relaxed enough for the placenta to be successfully delivered with controlled cord traction. The mother’s fundus is now firm and a handbreadth beneath the umbilicus. Inspection of the vagina and perineum shows no tears. There was an initial gush of ~100 mL of blood which quickly subsided. Bleeding is now minimal. Just as the nurse informs you that the mother’s vitals are normal (pulse 90 bpm, BP 123/79, O2 sat 99%), the other RN enters the room to ask if Jenna is ready to visit with her husband and their healthy newborn. The case is complete.
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Date and Time |
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ID
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CC
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HPI: 4 Key Questions
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Hx of Pregnancy
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OBHx: Outcomes of previous pregnancies
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PMHx
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On Examination (O/E)
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GxPx |
GTPAL |
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G = Gravidity → total # of pregnancies |
G = Gravidity → total # of pregnancies
L = number of living children |
E.g., Patient has been pregnant 4 times. The first one ended in a miscarriage at 10 weeks, the second child was born healthy at 38 weeks, the third was carried to 23 weeks but was born stillborn and she is currently 35 weeks gestation with the fourth pregnancy.
This can be described as: G4P2 in GxPx format or G4T1P1A1L1 in the GTPAL format.
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First Stage |
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Latent Phase Duration: Nulliparous: <20h Multiparous: <14h Clinical Features: Contractions:
Changes in Dilation:
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Active Phase Duration: Nulliparous: 4-6h Multiparous: 2-3h Clinical Features: Contractions:
Changes in Dilation:
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Clinical Features (Latent & Active Phases):
Overview of Physician Role:
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Second Stage |
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Duration: Nulliparous: <2h (3 with epidural) Multiparous: <1h (2 w/ epidural) Clinical Features:
Overview of Physician Role:
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Third Stage |
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Duration: 30 minutes Clinical Features:
Overview of Physician Role:
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Fourth Stage |
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1-2 hour postpartum period Clinical Features:
Overview of Physician Role:
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Brandt-Andrews Maneuver (preferred): an abdominal hand secures the uterine fundus to hold it in a fixed position and prevent uterine inversion while the other hand exerts sustained downward traction on the clamped umbilical cord.
Reference(s):
Anderson, Janice M, and Duncan Etches. 2007. Prevention and Management of Postpartum Hemorrhage. www.aafp.org/afp. (October 12, 2023).
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Definition |
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Lack of placental expulsion within 30 minutes of delivery. This time period can be extended to 90 to 120 minutes in the absence of hemorrhage for births in the second trimester and third stages of labor managed without oxytocin. In 80% of term births, the placenta is expelled within 30 minutes and in 98% within 1 hour. |
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Etiology & Clinical Features |
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There are 3 types of retained placenta:
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Risk Factors |
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Complications |
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Most common complications include postpartum hemorrhage and postpartum endometritis. Uterine inversion is less common. Fatality is quite rare in high-resource settings. |
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Management |
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Indications for Intervention:
Management:
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Reference(s) Erickson, A. & Parker, J. (Eds.). (2023). Toronto Notes 2023: Comprehensive Medical Reference and a Review for MCCQE. Toronto Notes for Medical Students Inc. Weeks, A. (2023). Retained placenta after vaginal birth. In Barss V (Ed.), UpToDate. Retrieved August 9, 2023 from https://www.uptodate.com/contents/retained-placenta-after-vaginal-birth?search=retained%20placenta%20after%20vaginal%20birth&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 |
IV: intravenous
IM: intramuscular
TXA: tranexamic acid
CCT: controlled cord traction
group and save: this is another term for type and screen or type and hold.
*Generic name ergometrine-oxytocin.
Reference(s):
Weeks, A. (2023). Retained placenta after vaginal birth. In Barss V (Ed.), UpToDate. Retrieved August 9, 2023 from https://www.uptodate.com/contents/retained-placenta-after-vaginal-birth?search=retained%20placenta%20after%20vaginal%20birth&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
| Signs of Placental Separation | |
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1. Gush of blood |
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| Active Management | |
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Drug Name |
Characteristics |
Side Effects |
PPH Usage |
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Medication Class: Oxytocics |
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Oxytocin |
Preferred first line uterotonic Stimulates muscle of upper uterine segment causing contraction to compress blood vessels IV: acts immediately IM: 3-5 minutes |
Rare: nausea, vomiting, headache, flushing Never give as IV bolus → hypotension, tachycardia & potential cardiovascular collapse possible Water intoxication with high doses, prolonged infusion, or hypotonic IV solution → Use normal saline or Ringers Lactate |
Prevention Vaginal Delivery:
Cesarean (elective):
Cesarean (intrapartum):
Treatment: 20-40 IU in 1000 mL normal saline, initially wide open |
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Carbetocin |
Long-acting oxytocin analogue Alternative agent if oxytocin is not available or consider if pt. is at high risk of PPH |
Nausea, vomiting, flushing, headache |
Prevention Vaginal Delivery: 100 mcg IM Cesarean: 100 mcg over ≥ 30 seconds Treatment: Limited data available |
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Medication Class: Ergot Alkaloids |
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Ergot Alkaloids |
Stimulates myometrium of upper AND lower uterine segments IM: 2-5 minutes IV: acts <1 minute (however, IV not recommended) |
Nausea, vomiting, hypertension Contraindicated in all hypertensive disorders of pregnancy |
Prevention: 0.2-0.25 mg IM Treatment: 0.2-0.25 mg IM (may repeat at 2h intervals) |
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Medication Class: Prostaglandins |
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Misoprostol |
Prostaglandin E1 Causes vasoconstriction & enhanced contractility of the myometrium |
Fever (most common with >600 mcg) |
Prevention: 400 mcg SL (SL achieves highest serum peak level) Treatment |
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Carboprost |
Prostaglandin F2α Causes vasoconstriction & enhanced contractility of myometrium |
Vomiting, diarrhea, fever, bronchospasm Use with extreme caution if asthma or major cardiovascular, renal, or hepatic dysfunction) |
Treatment |
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Medication Class: Tranexamic Acid |
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Tranexamic Acid |
Not a uterotonic Inhibits fibrinolysis Consider in pt. at very high risk of PPH |
N/A |
Prevention Vaginal Delivery: 1 g IV over 10 minutes within 10 minutes after vaginal delivery Cesarean: 1 g IV over 10 minutes before skin incision Treatment |
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Reference(s):
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.
Choosing a Debrief Framework:
A good debrief has been identified in the literature as the most important part of a successful simulation experience. If you're a novice or inexperienced facilitator, use this table to help you choose which debrief framework you want to use, just tap the button on their name and you will be directed to the appropriate aids or scripts. While we recommend the PEARLS framework, take a look to see if there may be another that is a better fit for your situation.
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Time |
Facilitator Level |
Prep Time |
Scenario Type |
Flexibility |
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Moderate |
Novice |
Moderate |
Any |
High |
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Short-Moderate |
Novice |
Low |
Short w/ Clear Objectives |
Low |
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Moderate |
Novice |
Moderate |
Any, esp. Team-focused |
Moderate |
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Very Short |
No experience |
None |
Any |
Low |
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Short |
Novice |
Low |
Low number of non-technical skills |
Low |
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Very Short |
No experience |
None |
Any |
Moderate |
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Moderate-Long |
Novice |
Moderate |
Any |
Moderate |
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
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Phase |
Objective |
Task |
Sample Phrases |
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1. Setting the Scene |
Create a safe context for learning |
State the goal of debriefing; articulate the basic assumption |
“Let’s spend X minutes debriefing. Our goal is to improve how we work together and care for our patients.” “Everyone here is intelligent and wants to improve”
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2. Reactions |
Explore feelings |
Solicit initial reactions and emotions
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“Any initial reactions?” “How are you feeling?” |
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3. Description |
Clarify Facts |
Develop a shared understanding of the case |
“Can you please share a short summary of the case?” “What was the working diagnosis? Does everyone agree?”
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4. Analysis |
Explore a variety of performance domains:
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See bottom of guide for details on the analysis phase |
For each item to be debriefed: 1. Preview Statement: (to introduce topic)
2. Pick Analysis method + Analyze: (see below for more info on each method)
3. Mini Summary: (to summarize discussion of topic)
Phase Wrap-up: "Any outstanding issues or concerns before we start to close?" |
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5. Application or Summary |
Identify take-aways |
Can be learner- or instructor-centered |
Learner-centered: “What are some takeaways from this discussion for our clinical practice?”
Instructor-centered: “The key learning points for the case were [insert learning points]”
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Analysis Phase Details |
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Choose an analysis approach (Different approaches can be used for different topics within the same analysis stage): |
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Approach |
Objective |
Sample Phrases |
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Learner Self-Assessment
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Promote reflection by asking learners to assess their own performance |
“What aspects were managed well and why?”
“What aspects do you want to change and why?”
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Focused Facilitation
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Probe deeper on key aspects of performance, uncover mental frames guiding performance |
Use Advocacy-Inquiry Method Advocacy: "I saw [observation], I think [your point-of-view]” "I noticed [observation] I liked that/I was concerned..." Inquiry: “How do you see it? What were your thoughts at the time?” |
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Provide Information
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Teach to close clear knowledge gaps as they emerge and provide directive feedback as needed |
“I noticed[behaviour]. Next time you may want to consider [suggested behaviour], because [rationale]” |
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PDF from debrief2learn.org: Here
Visual Guide: debrief2learn.org
Alternative Script: Here
Originally Created by: Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
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Phase |
Goal |
Actions |
Possible Scripts |
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Gather (Listen)
25% |
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How do you feel? |
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How do you think it went? Can you tell me what happened? |
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Can anyone add anything to that account? |
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Analyze (Guide Reflection)
50% |
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I noticed… |
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I noticed…. What was the thought process behind…. When….happened, I saw….What do you think….. I saw…I think….How do you see it? |
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Tell me more about… How did you feel about…. I understand, but tell me about X aspect of the scenario |
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Summarize (Help gather Conclusions)
25%
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What are two things that you thought were effective or went well? |
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What do you think are some areas you/your team need to work on? |
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In today’s session, we…. Going forward, we should…. |
References/Adapted From:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
Instructions:
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Actions |
Gather |
Analyze |
Summarize |
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Closed-loop communication
Clear Messages
Clear Roles
Knowing one’s limitations
Knowledge Sharing
Constructive Intervention
Reevaluation and Summarizing
Mutual Respect
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Student Observations
Instructor Observations
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Done Well
Needs Improvement
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Student-led Summary
Instructor-led Summary
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References/Adapted from:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
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Set learning objectives |
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After Case |
How did it go? Address Concerns Review learning points Plan ahead |
Framework from:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Diamond Debrief: Sample Phrases |
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Description |
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“So what happened?...and then what happened next?”
Continue asking until confident that the details of the scenario have been raised by the learners
“Let’s not judge our performance now, let’s just focus on what happened” |
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Transition |
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“This scenario was designed to show…”
“Let’s address technical and clinical questions. What is the protocol for…?”
“How do we normally deal with this clinical situation?”
“Everyone ok with that?” |
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Analysis |
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“How did that make you feel?” To participants, then group “Why?” Then use silence
“How did you/they do that exactly?” “Why did you respond in that way? “ or “Why did you take that action?”
“It feels like…was an issue. Did it feel like that to you?” What I’m hearing from you is…is that correct?”
“This is part of…” (identify the non-technical skill/human factor) “We refer to that as a human factor or non-technical skill, which means…” |
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Transition |
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“So, what we’ve talked about in this scenario is…” “What have we agreed we could do?” |
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Application |
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“What other kinds of situations might you face that might be similar? How are they similar?”
“How might these skills we discussed play out in those situations?”
“What are you going to do differently in your practice going forward?” |
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Underlying Principles |
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Description |
|
Reinforce a safe learning environment. Situate the debrief in the shared and meaningful activity that occurred. Keep the focus dispassionate—discuss what happened but avoid focus on emotions. Listen for emotional responses but resist the temptation to discuss emotions. Make sure everyone shares the same understanding of what happened.
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Transition |
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Transition into analysis by clarifying any technical and clinical issues |
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Analysis |
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Spend most of your time in Analysis. Deconstruct behaviours into specific actions, and explore what happened in detail. Ask about affective responses and validate them. Analyze and interpret the activity by applying appropriate frameworks or lenses (such as non-technical skills, or the clinical context surrounding the scenario). Keep discussion positive, and avoid the temptation to focus on “strengths and weaknesses”. Reflect responses back, allowing participants to amend or augment. |
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Transition |
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Transition into Application by reinforcing learning. |
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Application |
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Focus on moving from the specifics of the scenario to the more general world of practice. Break behaviours down into specific actions. Explore the other kinds of situations that these might apply to. Ask what participants will do differently in their practice. |
Adapted From: Jaye P, Thomas L, Reedy G (2015). 'The Diamond': a structure for simulation debrief. The Clinical Teacher 12(1). 171-175. onlinelibrary.wiley.com/doi/full/10.1111/tct.12300
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
Pluses:
Deltas:
|
Plus (+) |
Delta (∆) |
References:
((To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Phase |
Purpose |
Process |
Sample Phrases |
|
Reactions |
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How are you feeling? What are some initial reactions to what just happened? So, in that scenario… |
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Analysis |
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1. Observe an event or result. Comment on the observation.
2. Advocate for your position |
I saw that… I think… I noticed that…To me…
I saw…I’m concerned that… |
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3. Investigate basis for learner’s thinking that led to the observed event or result |
What do you think? Why do you think that happened? How do you see it? What was the thought process behind….? |
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4. Close the gap through discussion and didactics |
I hear…. What would it take for you to do this next time? How could we do this differently next time? I think a few good ideas that came up were… I’d like to say a little bit about…from my experience/literature |
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Summary |
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What are some takeaways from today? What went well today? What would you do differently next time?
In today’s session, we…. Going forward, we should… |
Adapted from:
Third Stage of Labour:
